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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton'Ave.':y '.S'tocktori, Calif. <br /> Telephone: (209).,466'-6781 f, <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-(� 5-is <br /> THIS.PERMIT-EXPIRES;.1 ,YE:ARfFROM DATE ISSUED Date Issued ? 3,­7 2/ <br /> (:Complete jIw Triplicate) <br /> Application�is.her y;.madeato .the_�-San,Joaquin .Local Health District. fora permit to construct <br /> and/or 'install the work herein described. This-'application is made in compliance with San Joaquin <br /> County. Ordinance•No-. X1862:.and-J.the-.Rules:F and,r,Regulat-ions' of the San Joaquin Local Health District. <br /> r.l <br /> JOB ADDRESS/LOCATIONIn <br /> T <br /> � `:� CENSUS TRACT' >„ <br /> •s4 y vr... (``"![' „.r?�I;�U�€i:y 'TQ 1..�-s=s�-,.�4^ =>A23 �� , ¢i°'3� 'v 3 _ ,_... .. . . .,. .. - <br /> Owner':s,,Name; Phone <br /> ri <br /> Address � ti� <br /> City <br /> Contractor's Name y[ , � ,z�,,� A. i� �Z_ � � <br /> _ ��,i fJ,A License �� � ,3 Phone � -3 <br /> TYPE OF WORK- (Check).:- NEW ,WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 yy <br /> t r. <br /> -. 'PUMP INSTALLATION / PUI REPAIR % PUMP REPLACEMENT /_7 <br /> Other' / <br /> r. ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE . TYPE OF WELL i CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/publi.t 'Driven ..-- -x_-- -Gauge of Casing <br /> Irrigation Gravel ,Pack Depth of Grout Seal <br /> Other Rotary Type of Grout - -- . <br /> Other Other Information ' ' <br /> PUMP INSTALLATION,:.,. -Contractor <br /> Type' of Pump H.P. <br /> _ T - <br /> PUMP REPLACEMENT: / / State Work Done k <br /> i <br /> PUMP REPAIR: / / State Work Done Pd& S 0 <br /> .DESTRUCTION OF WELL: Well Diameter '7"-"�w-��-.�.���✓ - T <br /> Approximate Depth { <br /> Describe -Material and Procedure <br /> t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. r <br /> SIGNED f`, {� TITLE ' <br /> ! <br /> (DRAW PLC PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FO DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY _ �_ f DATEU <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE 'I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL,INSP ON. <br /> E H .1426 4/72 1M m <br />